Author: Carolina Coleman

Medi-Cal Managed Care: Raising the Bar for Quality and Outcomes

To realize better health outcomes, Medi-Cal Managed Care (MMC) plans have many challenges to confront. Plans must tackle the tasks of ensuring that provider networks are of sufficient size, coordinated, high performing in service quality, and engaging patients to be critical partners in improving their health. These achievements require a great deal of investment and the right incentives to maintain systems in the longer term.

Health plans, providers, and the California Department of Health Care Services (DHCS) are implementing new policies and systems in service of these aims. These innovations and advancements are particularly important for many newly eligible beneficiaries who have a different health profile and care needs than previously eligible beneficiaries. Health plans are addressing these challenges in a variety of different ways, which depend on their local managed care environment, provider networks, and service delivery models. This paper highlights some of these efforts across the state, with a focus on successes that different organizations have seen and what promise they might hold in the future.

For this project, we interviewed a range of stakeholders from health plans, providers, independent practice associations, community clinics, and county health departments. Their opinions and expertise were compiled in the following paper and considered in our recommendations.

ITUP recommends that:
1. DHCS take on a more active oversight role
2. DHCS and MMC plans standardize data collection and increase transparency in performance reporting to the public and to providers
3. DHCS serve as an assertive facilitator and promoter of innovative best practices in value-based payment and delivery system reform
4. MMCs expand member engagement programs to reach new managed care populations
5. DHCS develop mental health and substance use disorder services quality performance metrics
6. All safety net delivery systems use the §1115 waiver to coordinate managed care with carved out services, with the aim of integrating delivery systems as soon as possible
7. MMCs include carved out providers in risk and shared savings programs

Download the paper here.

managed care pie chart


Covered California January Board Meeting

New year, new Covered California board meeting. Here are the details from the first meeting of 2015.

Plan Certification and New Entrants

A new policy was adopted for recertifying plans for the 2016 plan year and welcoming bids from insurance companies that have not previously participated in the Exchange.

New entrants will be considered in the following scenarios:

  • A plan is newly licensed in California
  • A Medi-Cal Managed Care plan chooses to expand into Covered California
  • Plans that have not previously offered in Covered California can join the Exchange only in counties with less than three current plan options (Regions 1, 9, 11,12, and 13)
  • SHOP welcomes bids from all plans
  • No new dental plans will be considered

New plans will have to apply to Covered California by May 1. New entrants in SHOP will have the ability to begin offering coverage as early as October, due to the expiration of non-ACA compliant plans in the small group market.

Standardized Benefit Design

A standardized benefit design for 2016 was adopted, with a few minor changes from what staff proposed in December.


  • The Silver tier will offer just one standard plan (no separate copay/coinsurance plans, although this remains in other tiers and in SHOP)
  • Deductible exemptions will remain the same
  • Outpatient surgery and all inpatient services in Silver is all 20% coinsurance, while all other services are simple copays.
  • The Silver structure in SHOP has changed to feature $1,500 medical and $500 brand pharmaceutical deductibles.

Bronze & Catastrophic

The Bronze structure proposed last month (in which lab work and outpatient rehab are exempt from the deductible, but the deductible increases to the out-of pocket maximum amount of $6,500) was adopted, however a HSA option with a $4,500 deductible and 40% coinsurance on most services will also be available.

A catastrophic plan with a $6,850 deductible and out-of-pocket maximum will also be available. Three non-preventive primary/urgent care/mental health visits will remain exempt from the deductible in Bronze and Catastrophic.

Gold and Platinum plans will stay essentially the same. There may be changes to the benefit design later, contingent upon the outcomes of Covered California’s work with stakeholders on high-priced specialty drugs. The full benefit design structure can be viewed here.


Close to 230,000 new consumers have enrolled in Covered California plans through January 12. Some great demographic data was revealed, and it’s pretty interesting to compare the statistics to those from year one.

While the percentage of enrollees receiving premium assistance (88%) and the distribution of metal tiers is exactly the same as the outcomes from last year (62% Silver, 26% Bronze), more Californians are enrolling through agents and the service center and more millennials are signing up. The table below points out some intriguing trends in enrollment by ethnicity – the racial demographics currently resemble those of open enrollment last year, while those who have completed the application process but have not picked a plan are totally different, with much higher percentages of Latino and Black consumers. Covered California is asking agents, CECs, and call center staff to reach out to those who haven’t selected a plan to help them understand their options and cross the finish line.

enrollment by ethnicity

Covered California marketing is in full swing, targeting certain communities through tailored messaging and mediums.


The newest challenge for the Exchange is providing subsidy reconciliation document to enrollees. Individuals who received premium assistance in 2014 will receive a 1095A form, which will detail the quantity of subsidies received, from Covered California, then consumers will use this form in filing their taxes. A press event focusing on 1095As is planned for Tuesday, so look out for more info then.

Enrollment Assistance

A change in compensation structure of Navigator Program was adopted. While Navigators are supposed to be paid in installments when they meet enrollment goals, the enrollment progress has been difficult to assess in a timely manner because the milestones are based on effectuation (plan selection AND premium payment). Navigators claim that they are providing extensive assistance to consumers in ways that don’t count towards the milestones, such as help understanding notices, renewals, and Medi-Cal enrollment. Covered California has decided to base the second payment on plan selections rather than effectuation so that the Navigators can fund their continued important work. Staff also indicated that additional changes to the Navigator and in-person assistance programs may come in the next few months.

Other Things We Learned

  • CalHEERS is working four times faster than it did last year
  • The service center has drastically improved response times – the percentage of calls answered within 30 seconds increased from less than 8% in November to 48% in January
  • Current carriers intend to expand coverage in regions 3 and 6

No meeting is planned for February so the Exchange can focus on the last days of open enrollment. As always, the meeting materials are available on the HBEX website.

Governor’s Budget Proposal – Health Analysis

It’s Budget Day! Governor Brown released his proposed budget this morning for 2015-16. Before we dive deep into the details of the health budget, here are the most noteworthy proposals:

  1. Annual enrollment periods for Medi-Cal – currently, Medi-Cal managed care members can change their plan once a month, in contrast to Covered California, in which consumers can generally only change plans during annual open enrollment. The current Medi-Cal policy allows for maximum member choice but disrupts continuity of care and care management efforts. The Budget proposes limiting Medi-Cal plan selection to a 90-day annual open enrollment period, creating savings of $1.6 million. If implemented, this would be a big change for Medi-Cal members, plans, and providers.
  1. The CCI may be put on the chopping block – the Coordinated Care Initiative has had a rough start, with 69% of dual-eligibles opting out of Cal MediConnect (more than double initial projections) and a 4% tax on managed care plans that funded the CCI was recently nixed by the Feds. There is concern that without the tax revenue the program will not be cost-effective, which would require the state to discontinue the CCI. The Budget specifies that if cost-effectiveness is not achieved by January 2016, then the program will cease operations.

A quick summary of the Medi-Cal budget:

Out of the $95 billion total Medi-Cal budget, General Fund spending on Medi-Cal will increase by 4.3% in 2015-16, to a total of $18.6 billion. Estimates for the Medi-Cal caseload have increased from nearly 12 million members to 12.2 million (although there were as few as 7.9 million members in 2012-13) in 2015-16, accounting for 32% of the state’s total population. While the federal government has picked up most of the tab for new Medi-Cal enrollees, the Budget estimates net costs of $14.3 billion in 2015-16 for the Medi-Cal expansion.


Screenshot 2015-01-09 11.37.32

Other very fascinating proposals (and lack thereof):

The Budget makes no changes to Medi-Cal provider rates. The federal bump ended in December and a 10% primary care rate cut kicked in in January.

Counties will receive an additional $150 million to conduct Medi-Cal eligibility determinations.

Members of state limited benefit programs (like CCS, AIM, GHPP, and Every Woman Counts) will be required to seek full-scope Medi-Cal or Covered California before they can receive services from non-comprehensive programs.

$300 is million allocated to pay for high cost Hepatitis C drugs like Sovaldi for Medi-Cal members, AIDS Drug Assistance Program (ADAP) participants, California state inmates, and state hospital patients.

Treatment for kids in Medi-Cal with Autism Spectrum Disorder (a new benefit, as required by the Feds) will cost $190 million in 2014-15 and $320 million in 2015-16.

Implementation of overtime for IHSS workers is on hold pending a federal court decision, but the 7% cut to authorized IHSS hours will be restored.

The pediatric palliative care pilot project has been deemed a success and will expand to seven new counties.

A new managed care tax will replace the tax that was recently deemed impermissible, relieving a $1.1 million General Fund offset.

Recertification of Drug Medi-Cal providers is expected be completed by November.


The full budget can be read here.

Covered California December Board Meeting

This month’s Covered California board meeting was quick and simple, focusing on open enrollment, upcoming changes to the board, and changes to the plan contracts and standardized benefit design.

Board Changes
Bob Ross of the California Endowment announced that he is resigning from the board, effective December 31. He was nominated by former Senate pro Tem Darrell Steinberg, and now wants to allow new pro Tem Kevin de Leon to appoint a new member. Dr. Ross was very thankful for the support and work of everyone involved in Covered California’s launch. Additionally, members Susan Kennedy and Kim Belshe’s terms are set to expire at the end of the month, however they will stay on until the Governor nominates replacements.

Open Enrollment

One month into open enrollment, much has been going smoothly. Nearly 100,000 individuals have selected plans and many more have submitted applications. While December 15 was the enrollment deadline for January 1 coverage, this has been extended to December 21.

enrollment 12.14

So far, most enrollments (77%) have occurred with assistance from agents, CECs, and the call center. CECs and agents have reported easier processes this year with fewer obstacles. Some individuals, particularly young adults and mixed families, are experiencing issues with the new identity proofing process that verifies the identity of applicants through credit checks. More than 50% of enrollees have paid their first premium online immediately upon enrollment.

One of the biggest challenges to the renewal process has to do with individuals who were in Covered California plans in 2014, but are found “likely eligible” for Medi-Cal for 2015. These individuals are supposed to seamlessly transition to Medi-Cal with no gaps in coverage, however this has been difficult to implement, given that counties process Medi-Cal applications on different timelines than Covered California. Individuals in this situation can continue their Covered California coverage at full cost with no premium assistance while they wait for full approval from counties, or they can choose to cancel the Covered California plan, and Medi-Cal will be retroactive upon approval. There was some debate about Covered California’s ability to continue offering premium subsidies during the transition (until full-scope Medi-Cal is approved). Covered California is actively working with DHCS and the federal government to protect consumers as much as the law allows.

QHP Certification and Recertification
The board reviewed staff proposals for Qualified Health Plan (QHP) certification and new entrants policy. Under the proposal, which will be voted on next month, Covered California would allow insurance carriers that do not currently participate in the Exchange to offer coverage in 2016 only in counties that have limited competition and consumer choice (fewer than three current carrier options – totaling about 10% of consumers). UnitedHealthcare in particular expressed interest in offering plans through Covered California.

Alternative benefit designs will not be permitted in individual market but will be considered for SHOP. Regardless if the proposal is adopted, altered, or rejected, the Exchange will encourage current plans to expand into other regions and will allow Medi-Cal managed care plans and new entrants to participate for 2016.

Standardized Benefit Design

The board also discussed proposed changes to the standardized benefit design for 2016. The primary changes proposed are in the Bronze tier, aiming to lessen barriers to outpatient, routine care. Bronze would function more like a catastrophic plan in that the deductible would equal the out-of-pocket maximum ($6,500), however labs and outpatient rehab/occupational/speech therapy would be exempt from the deductible, and specialists would be added to the categories of providers (currently primary, urgent, and outpatient mental health care) for which consumers can use three visits without meeting the deductible.


Silver plans would be simplified and focus more on copays rather than coinsurance. The staff is also developing recommendations on specialty drug pricing regulations and tweaks to complying with mental health parity law. Stay tuned as those develop.


Meeting materials are available on the HBEX website here. Month one down, two more to go. Happy holidays, and we’ll check back in January with the latest news from Covered California.

Covered California November Board Meeting

If you didn’t catch our live-tweet session during yesterday’s Covered California Board Meeting, now’s the time to catch up. The quick meeting reviewed the start of open enrollment, next steps, and previewed considerations for 2016.

Open Enrollment Updates

The Covered California Bus Tour was incredibly successful and the “I’M IN” campaign is fully underway (you can even add an I’m In badge to your Facebook profile picture). The Covered California website was also recently relaunched with additional resources and information in simple terms.


In just the first four days of open enrollment more than 69,000 individuals completed an application and were found eligible for either Covered California or Medi-Cal (it took 15 days to reach this number last year!). More than 11,000 of these Californians selected Covered California plans. Looking good! Renewals are also in progress, with enrollees able to switch plans through December 15 for January 1 coverage, or do nothing and be auto-enrolled in the same plan for 2015.

DMHC Audit

The Department of Managed health Care (DMHC) released a report earlier this week detailing a survey the Department conducted of providers listed in the Covered California networks of Anthem Blue Cross and Blue Shield plans. This secret shopper survey contacted 3,272 Anthem providers and 1,360 Blue Shield doctors in June and found discrepancies between the official directories and reality. For Anthem, 13% of those surveyed claimed to not accept Covered California plans, while 9% of Blue Shield providers said the same. Additionally, 13% of Anthem providers and 18% of Blue Shield providers said that the provider listed did not practice at the listed location. About 88% of Anthem providers and 91% of Blue Shield providers reported accepting new Covered California patients. These findings are clearly troubling and Covered California has been aware of these issues. The plans have been working to correct the problems and Covered California is working to educate providers about Covered California and plan contracts. Expect a lot more work on this issue as DMHC conducts a follow up audit and Covered California continues to monitor changes.


CalHEERS has undergone a number of systems improvements but, with so many priorities, still has many on the to-do list. Voter registration and first premium payment are live! There have been some tech hiccups on renewals that are being worked on. There are a number of efforts to improve the Medi-Cal enrollment process through CalHEERS, however the programming for disenrollment from Medi-Cal is on hold until after open enrollment The next big project to go into effect is the 1095 notices, which are IRS forms detailing coverage and premium subsidies for reconciliation, that should be completed in January. In the long term, SAWS integration will be a key area is future efforts.



A competitive bidding process is coming for contracts related to consumer research, marketing, CalHEERS support, and accounting services. The Exchange extended contracts for the Consumer Health Alliance, the Department of Social Services, and the provider education grants. New contracts have been awarded to forms doing targeted, ground level outreach to the Latino, African American, and API communities.


Other issues discussed:

  • Enrollment assistance and eligibility and enrollment regulations were readopted with minimal changes.
  • The benefit design workgroup has been discussing how the standardized benefit design for plans should change in 2015. Areas of focus include increasing transparency of costs, reducing coinsurance use, and lessening barriers to care.

Next month’s meeting has been moved to December 15 and will focus on QHP issues, including consideration of whether to allow currently non-participating insurance companies to join the Exchange. As always, all meetings materials are available on the HBEX website.

Sign Up for Coverage: It’s Easy as 1, 2, 3

In case you haven’t heard: open enrollment for Covered California and other private individual plans begins tomorrow! ITUP is super excited and has been celebrating on the Covered California bus all week. Now we have a quick message you can deliver to friends, family, and clients: signing up for coverage can be as easy as 1, 2, 3.

1. Gather documents and fill out the online application

Ready to get insurance? First, you’ll need information about income, like paystubs, and the social security numbers for everyone in your family applying for coverage and who you file taxes with. If you are an immigrant, grab any paperwork or identification. Then you can fill out the application through or contact an enrollment counselor or insurance agent to help you apply.

2. Choose your plan

Once your application has been submitted, you’ll receive an eligibility determination for financial assistance, and then you get to pick a plan that works for you. Here are some important factors to consider:

  • Premium cost
  • Outpatient providers in network
  • Hospitals in network
  • Drug formulary
  • HMO vs. PPO vs. EPO
  • Premium and cost-sharing trade off between metal tiers
    • How much care do you anticipate using?
    • Do you qualify for cost-sharing subsidies?


3. Pay your premium

Big deal alert – starting this year, consumers will be able to make their first premium payment upon enrollment through the Covered California system. This streamlines the process and will hopefully speed up activation of coverage. Enrollees who don’t immediately pay their first premium will receive a bill from the insurance company with a due date.

It’s as simple as that. Still have questions? Ask ITUP at Happy enrolling!


Covered CA Bus Makes the Rounds

This morning our state’s health insurance exchange took off on a road trip. Covered California staff, stakeholders, and supporters loaded up on a custom bus for a nine day trip with stops in 21 cities to get the message out: affordable health care is here. ITUP is excited to participate and will be live tweeting all week (there may even be a couple of selfies in there)!


The bus tour is just in time for open enrollment, which begins on SATURDAY November 15, and goes through February 15. With half as much time to enroll Californians as last year, we’ve got a huge task on our hands.


If you want to help get the word out, join us at one of the bus stops, or follow Covered California on Twitter.
Monday, November 10

8 a.m. Sacramento West Steps, Capitol, 10th Street and Capitol Avenue Sacramento 95811

11 a.m. Petaluma Redwood Community Health Coalition, 1310 Redwood Way, Suite 135 Petaluma 94594

1:30 p.m. San Francisco Jesse Square, Yerba Buena Gardens, 736 Mission Street San Francisco 94103

5:00 p.m. San Jose Yerba Buena High School Library, 1855 Lucretia Ave San Jose 95122

Tuesday, November 11

9 a.m. Merced Healthy House Within a MATCH, 301 W 18th Street Merced 95340

11:30 a.m. Fresno Fresno Black Chamber of Commerce and West Fresno Family Resource Center, Downtown Business Hub, 1444 Fulton Street Fresno 93721

4 p.m. Bakersfield Central Bakersfield Health Center/Clinica Sierra Vista, 301 Brundage Lane Bakersfield 93304

Wednesday, November 12

7:30 a.m. Pasadena Chapcare Storefront, 316 E. Colorado Blvd. Pasadena, CA 91101

8:00 a.m. Pasadena Pasadena City Hall, 100 N Garfield Ave Pasadena 91101

11 a.m. Riverside/ Moreno Valley Moreno Valley Public Library, 25480 Alessandro Blvd Moreno Valley 92553

2:30 p.m. Palm Springs Desert Healthcare Foundation, 1140 N. Indian Canyon Dr, 2nd Floor Palm Springs 92262

Thursday, November 13

10 a.m. San Diego San Diego Convention Center Conference Room 16AB, 111 W Harbor Dr. San Diego 92101

2:30 p.m. Orange County/La Habra Institute for Healthcare Advancement, 501 South Idaho Street, Suite 300 La Habra 90631

Friday, November 14

12 p.m. Los Angeles Grand Park LA, 200 N Grand Ave Los Angeles 90012

3 p.m. Los Angeles HOLD: Drew University, 1731 E 120th Street Los Angeles 90059

Saturday, November 15

9 a.m. San Bernardino National Orange Show Events Center, 620 S. Arrowhead Ave. San Bernardino 92408

10 a.m. Los Angeles Eisner Pediatric 1530, S Olive Street Los Angeles 90015

Noon Los Angeles AltaMed Commerce Site, 5427 Whittier Blvd. Los Angeles 90022

1:00 p.m. Orange County Enroll OC (Congresswoman Sanchez Event) Plaza Santa Ana, 4th Street and French Street Santa Ana 92701

2:30 p.m. Carson Kelly Rolfe Financial storefront, 9100 South Sepulveda Blvd Los Angeles 90045

3:30 p.m. Los Angeles Crenshaw Mall storefront, Baldwin Hills Crenshaw Mall 3650 W Martin Luther King Jr Blvd Los Angeles 90008 (2nd floor near Sears)

Monday, November 17

9 a.m. Santa Barbara TBD

Noon San Luis Obispo TBD

4:30 p.m. Salinas TBD

Tuesday, November 18

9:00 a.m. Yuba City Yuba City Medical Center, 1000 Sutter Street Yuba City 95991

11:30 a.m. Chico Enloe Medical Center, 1531 Esplanade Chico 95926

3 p.m. Redding Shasta County Child Abuse Prevention Coordinating Council, 2280 Benton Dr. Bldg C, Ste A Redding 96003


Coverage Resources Available: Help with Complaints & Concerns

Today on Ask ITUP we have a question on where to go for concerns, complaints, and questions.

How can consumers make complaints about coverage?

It depends on the type of concern. For example, insurance companies have formal grievance processes for claim and prior authorization denials. Some folks have complaints about narrow networks they are taking up with both the health plan and the Department of Managed Health Care (for HMOs) and Department of Insurance (for PPOs). Covered California has an appeals process for eligibility and subsidy determinations, as well as disenrollment and individual mandate exemptions determinations.

For Medi-Cal, go to the county Department of Public Social Services (or Human Services, in some counties) for eligibility issues. Information on care/claims denials and access to care issues should be sent to the managed care plans, the Office of the Patient Advocate, or the Medi-Cal Managed Care Ombudsman, or to the county offices if you receive fee-for-service Medi-Cal. You also have a right to request a fair hearing within 90 days of a denial or service

To initiate a grievance with a health plan, simply call the member services number on your insurance card and state that you would like to file a compliant. Plans must review complaints in a timely manner. If you go through the grievance process with a plan (private or Medi-Cal) and you do not agree with its decision, then you can ask the State to review the complaint.

Here are some resources for where to take concerns, ask for help, and get more information. The Office of the Patient Advocate is a great place to start.

Screenshot 2014-11-04 12.06.05


Health plan help:
Office of the Patient Advocate California
Consumer Assistance Program

Department of Managed Health Care

Department of Insurance

Medi-Cal questions:
Managed Care Ombudsman

County Social/Human Services Offices

Health Care Options

Covered California appeals:

Access & eligibility issues:
Health Consumer Alliance

Medicare questions:
Health Insurance Counseling & Advocacy Program


Have a health policy question? Email!

Ask ITUP: Estate Recovery and Assets Tests

Two technical topics today: asset testing and estate recovery in Medi-Cal.

What is “Medi-Cal look-back?”

While the ACA abolished asset testing ($2,000 limit on applicant’s assets, with requirements that consumers must “spend down” to $2,000) for most beneficiaries, they still apply to individuals with disabilities who apply through SSI, those 65 or older, and anyone who utilizes long-term care services such as nursing homes. Individuals in long-term care only must not have transferred assets (e.g. moved money to family members or sold for less than fair market value) within a certain period of time before the eligibility determination, referred to as the “look-back period.”

The time frame for the look-back differs in federal and state law – the Department of Health Care Services has historically used a 30 month period, while federal law calls for a look-back of five years.

If someone did transfer assets during the look-back, they are subject to a waiting period, and are essentially barred from long-term care benefits for the length of time equivalent to the asset transfer divided by a state average cost of care per month. The most recent figure available for the monthly cost of nursing care is $7,628.

Individuals concerned about Medi-Cal look-back or planning for long-term care should consult an attorney.


Who is subject to estate recovery in Medi-Cal, and how does it work?

The Estate Recovery Program, through which the government can recoup the cost of care from a beneficiary’s estate after his/her death, is a common concern amongst individuals eligible for Medi-Cal. Here are the facts:

  1. Only individuals 55 or older and beneficiaries in long-term care are subject to estate recovery.
  2. There are numerous exemptions to estate recovery including instances when:
  • A spouse is alive (recovery can be made after the death of the spouse)
  • Beneficiary had a minor, blind, or disabled child
  • There is nothing left in the estate
  • Heirs can apply for hardship exemption
  1. Recovery is limited to the cost of care a beneficiary received, however if the individuals was enrolled in managed care, the PMPM can be collected.
  2. Upon death of the beneficiary, the State becomes a party in the beneficiaries’ will. The State must split any balance in the estate with any other heirs or individuals bequeathed.
  3. The State can never seize a beneficiary’s home, but when the property is eventually sold, the State may be entitled to some of the profits. The State can impose a lien on a beneficiary’s home if he/she enters long-term care and does not intend to return home. Liens cannot be placed if a spouse, minor/blind/disabled child, or sibling lives in the home.
  4. The State does very little actual recovery, because most Medi-Cal beneficiaries have relatively few assets. In 2013, it recovered $59.4 million, about 0.1% of Medi-Cal expenditures.

California Advocates for Nursing Home Reform’s thorough summary of Estate Recovery is a valuable resource for talking about estate recovery with individuals eligible for Medi-Cal. Once again, individuals concerned about estate recovery should consult a lawyer. Finally, the Legislature and the Governor have expressed interest in narrowing the estate recovery eligibility criteria and/or the circumstances in which the State can make a recovery – we will keep you posted on any changes.

Introducing “Ask ITUP”

ITUP is launching a new column that answers complicated questions about health reform. As open enrollment approaches (November 15!), you may have burning questions – send them our way! Email for questions and technical assistance. Answers will be posted here on the ITUP blog for all to benefit.

We have two questions for you today – one on calculating income and another potential eligibility changes.

I am confused about the maximum amount of money you can make to qualify for Medi-Cal. Some sources report $15,857 for one person, others say $16,105. What’s the difference?

Individuals are eligible for Medi-Cal up to 138% of the federal poverty level (FPL). When the feds released the FPL for 2013, one person making $15,857 was at 138% FPL. New numbers for 2014 have since been released, and now 138% FPL has increased to $16,105.

The bigger question is about when do the new year’s numbers go into effect. It’s tricky. Covered California uses the FPL that was in place upon the start of the plan year for the entire plan year, while Medi-Cal shifts to the most recent FPL in spring. This means that a small group of individuals just over the previous cut off line must shift from Covered California to Medi-Cal mid-year without a change in income. For applications submitted during the upcoming open enrollment period, eligibility for all coverage will be assessed using the 2014 FPL.

I heard that some immigrants are going to be moved from Medi-Cal to Covered California. Is this true?

Currently, California pays the entire cost of Medi-Cal coverage (except for emergencies & pregnancies) for low-income legal permanent residents who have been in the U.S. for less than five years, rather than sharing costs with the federal government. In the interest of saving state funds, California plans to shift some of these immigrants (adults without children) to Covered California, offering them additional state-funded premium and cost-sharing assistance.

Stakeholder meetings to develop this proposal (along with a similar program for pregnant women dually eligible for Covered California and pregnancy-only Medi-Cal) are underway, but it is unclear when the programs will launch. Stay tuned – we will keep you posted with any updates.

Check back soon for more Ask ITUP questions and answers.